State of California—Health and Human Services Agency California Department of Public Health Surveillance & Statistics Section

P.O. Box 997377, MS 7306

MALARIA CASE REPORT Sacramento, CA 95899-7377

Patient name–last first middle initial Date of birth Age Sex

Address (number, street or P.O. Box) City State County ZIP code

Telephone number

Home ( ) Work ( ) RACE (check one) ETHNICITY (check one)

❒ Hispanic/Latino ❒ Non-Hispanic/Non-Latino❒❒❒❒❒ African-American/Black White Native American Asian/Pacific Islander Other: _______________________

If Asian/Pacific Islander, please check one: ❒ Asian Indian ❒ Cambodian ❒ Chinese ❒ Filipino ❒ Guamanian ❒ Hawaiian

❒ Japanese ❒ Korean ❒ Laotian ❒ Samoan ❒ Vietnamese ❒ Other: ___________________

PRESENT ILLNESS Onset date (mm/dd/yy) Diagnosis date (mm/dd/yy) Hospitalized?

❒ Yes ❒ No Physician name Telephone number

( ) Admit date (mm/dd/yy) Discharge date (mm/dd/yy) Medical record number Hospital name Telephone number

( )

1. Clinical complications for this attack: ❒ Cerebral malaria ❒ Renal failure ❒ ARDS ❒ Anemia (Hb<11, Hct<33) ❒ None ❒ Other: ______________________

2. Was illness fatal? ❒ Yes ❒ No ❒ Unknown If yes, date of death (mm/dd/yy):_________________

3. Therapy for this attack (check all that apply): ❒ Mefloquine ❒ Tetracycline/doxycycline ❒ Pyrimethamine-sulfadoxine ❒ Chloroquine ❒ Quinine/quinidine ❒ Atovaquone-proguanil (MalaroneTM) ❒ Primaquine ❒ Exchange transfusion ❒ Unknown ❒ Other, specify:________________________________________

LABORATORY Lab results: ❒ Smear positive ❒ Smear negative ❒ No smear taken

❒ ❒ ❒ ❒ ❒Species (check all that apply): Vivax Falciparum Malariae Ovale Not determined Laboratory name Telephone number

( )

PATIENT HISTORY 1. Has the patient traveled or lived outside the U.S. during the past four years? ❒ Yes ❒ No ❒ Unknown If yes, specify below:

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Country: ________________ ________________ ________________ Date returned/arrived in U.S. (mm/dd/yy): ________________ ________________ ________________ Duration of stay in foreign country (days): ________________ ________________ ________________

2. Did patient reside in U.S. prior to most recent travel? ❒ ❒ ❒ ❒Yes, for > 12 months Yes, for < 12 months No—specify country: _____________________________________ Unknown

3. Principal reason for travel from/to U.S. for most recent trip: ❒ Tourism ❒ Military ❒ Business ❒ Peace Corps ❒ Visiting friends/relatives ❒ Airline/ship crew ❒ ❒ ❒ ❒Missionary or dependent Refugee/immigrant Student/teacher Other—specify: _____________________________

4. Was malaria chemoprophylaxis taken? ❒ Yes ❒ No ❒ Unknown If yes, which drugs were taken, please check below: ❒ Chloroquine ❒ Mefloquine ❒ Doxycycline ❒ Primaquine ❒ Atovaquone-proguanil (MalaroneTM) ❒ Other—specify: ________________ a. Were all pills taken as prescribed? b. If doses were missed, what was the reason?

❒ Yes, missed no doses ❒ Forgot ❒ No, missed one to a few doses ❒ Didn’t think needed ❒ No, missed more than a few, but less than half of the doses ❒ Had a side effect, specify:___________________________ ❒ No, missed half or more of the doses ❒ Was advised by others to stop ❒ No, missed doses but not sure how many ❒ Prematurely stopped taking once home ❒ Don’t know ❒ Other, specify: ____________________________________

5. History of malaria in last 12 months (prior to this report)? ❒ Yes ❒ No ❒ Unknown If yes, specify species below: ❒ Vivax ❒ Falciparum ❒ Malaria ❒ Ovale ❒ Not determined Date of previous illness (mm/dd/yy): _________________

6. Blood transfusion or transplant within last 12 months: ❒ Yes ❒ No ❒ Unknown If yes, date (mm/dd/yy): _________________ Investigator name (print) Date Telephone number

( ) Agency name

FOR CDC USE ONLY: Classification: ❒ Imported ❒ Induced ❒ Introduced ❒ Congenital ❒ Cryptic CDPH 8657 (07/07) (Department and address updated. This replaces 09/02 version. Please submit this case report VIA your CD reporting clerk.) Page 1 of 2

MALARIA CASE REPORT—CDPH 8657—Page 2 of 2

Malaria (Plasmodium spp.)

1995 Case Definition*

Clinical Description

Signs and symptoms are variable; however, most patients experience fever. In addition to fever, common associated symptoms include headache, back pain, chills, sweats, myalgia, nausea, vomiting, diarrhea, and cough. Untreated Plasmodium falciparum infection can lead to coma, renal failure, pulmonary edema, and death. The diagnosis of malaria should be considered for any person who has these symptoms and who has traveled to an area in which malaria is endemic. Asymptomatic parasitemia can occur among persons who have been long-term residents of areas in which malaria is endemic.

Laboratory Criteria for Diagnosis: Demonstration of malaria parasites in blood films.

Case Classification

Confirmed: An episode of microscopically confirmed malaria parasitemia in any person (symptomatic or asymptomatic) diagnosed in the United States, regardless of whether the person experienced previous episodes of malaria while outside the country.

Comment

A subsequent attack experienced by the same person but caused by a different Plasmodium species is counted as an additional case. A subsequent attack experienced by the same person and caused by the same species in the United States may indicate a relapsing infection or treatment failure caused by drug resistence.

Blood smears from questionable cases should be referred to the National Malaria Repository, CDC, for confirmation of the diagnosis.

Cases also are classified according to the following World Health Organization categories:

Autochthonous:

Indigenous: Malaria acquired by mosquito transmission in an area where malaria is a regular occurrence.

Introduced: Malaria acquired by mosquito transmission from an imported case in an area where malaria is not a regular occurrence.

Imported: Malaria acquired outside a specific area (e.g., the United States and its territories).

Induced: Malaria acquired through artificial means (e.g., blood transfusion, common syringes, or malariotherapy).

Relapsing: Renewed manifestation (i.e., of clinical symptoms and/or parasitemia) of malarial infection that is separated from previous manifestations of the same infection by an interval greater than any interval resulting from the normal periodicity of the paroxysms.

Cryptic: An isolated case of malaria that cannot be epidemiologically linked to additional cases.

*Source: http://www.cdc.gov/epo/dphsi/casedef/print/malaria_current.htm

CDPH 8657 (7/07) Page 2of 2